Working with pediatrics

Today we are honored to have a guest post from one of my RT pals, Paul Ritt,  who works for a pediatric unit in one of Michigans larger medical facilities.  So if you're interested in working solely with pediatrics, here's a little insight from the inside.

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Hi.  My name is Paul Ritt and I work for Better Life Hospital somewhere in Michigan.  I generally work with pediatric patients of a variety of sorts. We have a ped ICU which we refer to as PIC U for acutely injured kids, and a Peds ICU which is a long term center for mainly chronically ill kids.  The Peds ICU includes a vent dependent unit.  We also have a peds emergency room and a neonatal intensive care unit.  So there you have an overview of our facility. 

I knew from day one working in such a facility would be challenging, and sad at times, yet I love kids and I wouldn't choose to work anywhere else.  One of the neat things about working with kids is a sick kid is a sick kid.  What I mean here is there are a lot of adults who fake it just to get attention, or just to get out of work, or just to get social security.  Yet kids never fake being sick -- or fake it enough to end up in here anyway. 

I love taking care of kids because, to put it simply, I love kids.  I love their innocence.  I love the way they smile even in the face of tough sickness.  I find that kids have a way of seeing hope and happiness where many adults find dread and misery.  Kids just have a way of making life seem so simple.  I just love it.

Yet through it all you have your challenges.  For example, during RSV season we have our shot gun season.  It's based on what we like to call the shotgun effect.  I'm sure you've experienced some form of the shotgun effect where you work.  This is where you have a sick person and the doctor throws everything available at that patient in the hopes that something works.

In RSV season every patient admitted with, or suspected of, having RSV will get all of the following ordered:

• Ventolin
• Pulmicort
• Toby
• Pulmizyne
• CPT
• Suction

You can't do all those at the same time, so you are usually in the room anywhere from 20 minutes to an hour.  The nice thing is you get to spend quality time with the patient and get to know families.  You get to watch lots of Micky Mouse Clubhouse.  The down part is you are in the same room for too long doing wasteful procedures.

Another thing I hate is the PICU.  It's sad for one thing.  Yet often I think the PICU just creates patients for the Peds ICU.  We put some patients on ventilators and we create chronic lungers who require months in the ICU and then a lifetime of suffering from chronic illness. 

Granted sometimes kids need to be ventilated, yet many times I think they are just to make the doctor and nurses feel better, or to satisfy a guideline, or just to protect the airway during a flight in the medical helicopter.  Yes, the PICU is just creating a whole new group of patients, and YES the hospital makes money off these patients.

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Thanks Paul

Setting up vent on pediatric

Guidelines for Set-up of Servo for Pediatrics:

1. Pt Range: Pediatric (if ideal VT greater than 40cc or less than 400cc)
2. Mode: PC if less than 10kg, otherwise PRVC
3. VT: 5-7 cc/kg post-term to 14 YO
4. PIP: Not greater than 30
5. PEEP: Start 4 – 5 CWP
6. FiO2: 5 – 10% above pre-intubation adjust to maintain desired SpO2.
7. Rate: Normal for age
8. I-time: a. Maintain I:E of 1:2
9. I-Rise time: As appropriate for patient to create pseudo sign wave.
10. PIP limit: 2-3 greater than PIP (other alarms as appropriate)

For a printable cheat sheet with this information and more, click here.

For a cheatsheet on setting up ventilator for neonates, click here.

The ongoing drama of crying baby's and blowbys

I'm just curious here, but since most studies show that 90% of the aerosolized medicine is wasted when giving a blowby treatment, and a laminar flow is recommended for maximal impaction of the medicine to receptor sites in the lungs, how much of the medicine do you think a child is getting if he is wailing through the entire blowby treatment?

I bet it's less than 1%, although I'm not sure any studies have ever been done to determine this. Yet commonsense says that most of that medicine I just gave that 3 YO kid impacted outside that boy's body, and the rest never made it beyond is oral cavity.

And, sorry doc, but the treatment was pretty much useless. Although the doctor was convinced that it was my breathing treatment that cured that kid of his congested cough. Well, I've lost patience with doctors and nurses to explain again and again that crying baby's don't get the medicine, and blowby is pretty much useless.

I would give the treatment with a mask or mouthpiece to most kids who are compliant, but the blowby remains the only option for non compliant kids and babies. Now, personally, I don't think the treatment for congestion was indicated anyway, but I don't see any harm in trying. Still, he didn't get the medicine.

The irony of all this is neither the doctor nor the nurse considered any of this science. Nor the fact that my being in the room is merely causing that little boy serious anxiety, and better therapy would be for that kid to be left alone.

Although I'm not a well trained doctor, and I'm prone to be wrong from time to time, science is science, and science says blowbys and crying do not equal good impaction of aerosolized meds in the lungs.

Yet, from behind me, the nurse says, "It's okay that he's crying. He gets more of the medicine that way."

"Ahhhhhhh," I think. I say: nothing. I give up. I've already explained the science a million times. It never yet has sunk.

As soon as I stop the treatment the kid smiles at me, and says, "Thanks." Wow! That's all it took to make him better was for me to stop. Who would have thunk it? Oh, I did!

Yet, it often seems no doctor nor nurse ever seems to consider blowby and crying science as I finish the treatment. They usually simply ask this simple question: "Is he better?"

I say, "We'll have to wait and see, because I can't assess him at the moment because he don't like me much."

Crying NOT good during breathing tx's

When I'm giving a breathing treatment I get so tired of RNs and doctors telling moms and dads that it's okay that their kid cry during a breathing treatment. "They take in a deep breath and get more medicine that way."

"Ahhhhhhhhhhhhhhhhhhhhhhh," the RT thinks, hardly able to hold in his rage. He's sooooooooo sick and tired of stupid dummass theories.

NO! WHEN A BABY IS CRYING HE IS SPENDING MOST OF HIS TIME EXHALING. HE IS TAKING IN SHALLOW BREATHS, AND SPENDING MOST OF HIS TIME EXHALING. HE IS CAUSING TURBULENCE WITHIN HIS AIR PASSAGES, WHICH CAUSES THE MEDICINE TO IMPACT IN THE BACK OF THE MOUTH AND THE LARGE AIR PASSAGES. THUS, VERY LITTLE MEDICINE MAKES IT TO THE BRONCHIOLES. FOR BEST DEPOSITION OF MEDICINES...

...Ahem...

YOU WANT A SMOOTH LAMINAR FLOW DURING INSPIRATION FOR THE 0.2-0.5 MICRON PARTICLES IN THE BREATHING TREATMENT TO EASE THEIR WAY TO THE BRONCHIOLES AND CONNECT WITH BETA 2 RECEPTOR SITES IN THE LUNGS.

...Ahem...

A TREATMENT GIVEN WHEN A PATIENT IS CRYING IS ABSOLUTELY USELESS.

Can I make myself more clear? Of course Dr. Stanwich debated me on this, and insisted that I prove it.

Um, okay, so where the heck did I read that? What book was it in? Like you need to look at a book. What about just using some common sense. If you inhale fast, you are feeling more cool air at the back of your mouth.

Ladies and Gentlemen, boys and girls, I have found it in writing. Finally. Finally I can put an end to this Lame theory that it's okay for babies to be crying during a breathing treatment.

The breathing pattern is another consideration in using a nebulizer or inhaler with a child. Quiet tidal breathing is the best pattern for drug delivery. Crying is a problem during a nebulizer treatment due to high inspiratory flow during the short, rapid inspirations and prolonged expiration that result in a significant decrease in medication deposition in the lung.

If you don't believe me, check out this link to original article in the August 2008 issue of RT Magazine. The article is aptly titled, "Kids and Asthma: Making (and Teaching) the Right Choices." The author is Bill Pruitt, RRT, AE-C, CPFT.

Hey, you can base what you say on facts, or some dummass theory that takes a simple mind to repeat over and over and over. Take your pick.

I prefer to base what I say on fact.

Consider this RT Cave Rule #30.

Here are the lastest recommendations for RSV kids

Thanks to Ventworld.com, I've managed to come up with the latest guidelines on bronchiolitis and RSV as written by National Guidelines Clearinghouse at http://www.guidelines.gov/ and based on all the latest scientific research and studies.

These are not new to us RTs in the RT cave, but this is the first time I've actually been able to find all this information in one place. I guarantee you I will leave this lying around the hospital for everyone to read. Perhaps I can enlighten some people.

I would love it if our pediatricians would read this latest research and opt to change their guidelines, however I will not get my hopes up. Doctors at Shoreline, and those of other small town hospitals in this region, prefer to work with antediluvian research.

First and foremost, RSV SWABS are not recommended. I mention this in bold because we RTs have to do RSV swabs at Shoreline. Do other RT departments get stuck with this job? I have no clue.

Likewise, chest x-rays, cultures, capillary or arterial gases, rapid influenza or other viral studies are not recommended because "these studies are not generally helpful and may result in increased rates of unecessary admission, further testing, and unecessary therapies."

Likewise, chest physiotherapy and cool mist therapy (mist tents) are also not recommended "as they have not been found to be helpful."

Oxygen on these children, according to up to date studies, is only recommended if the SpO2 is "consistently less than 91%," and oxygen should be weaned when the SpO2 is "consistently higher than 94%."

This is what I tried to point out to an ER RN yesterday and she tried to debate me that I was wrong. I was not wrong. However, to give her credit, our policy is to place and keep all kids who are unable to maintain an SpO2 under 95% on oxygen.

And, surprise, that means they get admitted.

Here is the part of the protocol that might just cause some doctors to completely reject these new guidelines, because it's just not possible that Ventolin would have no effect on lungs that sound that bad.

But, the new recommendations regarding Albuterol is that it "not be routinely used" for the treatment of RSV and bronchiolitis. I must note here that I did not add the emphasis.

Look, as we RTs have been saying all along, we have no problem trying a breathing treatment. And these guidelines recommend trying one. But, if there are no observable changes noted as a result, then this therapy should be discontinued.

If a child is suspected of having asthma, or is at high risk of asthma, then lets place the child on prn breathing treatments, and give them as indicated, rather than just because.

Note the following: "Although in some cases bronchiolitis may be a prelude to asthma, in the majority of cases the use of inhalation therapies and other treatments effective for treating bronchospasm charicteristic in asthma will not be efficacious for treating airway edema typical of bronchiolitis."

Take that and smoke it in your peace pipe.

Keep in mind, however, that studies have shown Vaponepherine (Racemic Epinepherine) to have a beneficial effect on some RSV kids. So this provides another option for doctors to trial on these children, and discontinue if it has no observable benefit.

What is highly recommended is suctioning. And, to our surprise, our pediatricians listened to us when we recommended this a couple years back, and now we even have booger be gones.

This only makes sense, considering RSV involves secretions in the airway, mostly from sinus drainage caused by a virus isolated (in 75% of the cases) in the middle ear.

Secretions is what causes the SpO2 to drop in some kids, not bronchospasm. And that is why it is recommended to suction before feedings, as needed and prior to breathing treatments if they are indicated.

These guidlines are so impressive to me I almost wonder if they were written by a respiratory therapist.

The following was noted regarding suctioning:

"Suctioning itself may improve respiratory status such that inhalation therapy is not necessary... Suctioning may improve the delivery of the inhalation therapy" if the treatment is given.

I can't believe I'm actually reading this. This is incredible. We RTs have known this for years, and when doctors find this out, well, they'll probably chant something like, "Well, everybody has their opinion."

Setting up continuous pulse oximeters on children under one-years-old is pretty much standard practice around here. However, new research shows that the use of "continuous oximetry measurement has been associated with increased length of stay of 1.6 days."

And, therefore, it is recommended that the child's SATs be checked occasionally, but not continuously because some doctors use it as the sole criteria for admitting children and for keeping them in the hospital "one more day."

There you have it folks. That's the up to date state of the art recommendations by the worlds top pediatricians of the nations top children's hospitals. But, they must have it wrong, because that's not how we do things at this hospital.

Tired of people defending old, worn out policies

I'm going to get myself fired if I don't learn to keep my mouth shut, which is ironic because I'm not necessarily a talker. However I've had it with all the B.S. and I'm starting to have a difficult time keeping my thoughts to myself.

"Hey Rick," the doctor called to me as I was passing through ER. "Will you check a sat on the baby in room 5. We've been having trouble getting one."

"Sure thing."

Upon entering the room the child was sleeping comfortably in his mother's arms. I had already completed a blowby treatment on him about a half hour earlier and, needless to say, the treatment was not indicated. I also did an RSV swab on the kid, and that was ordered because the kid had a little snotty nose and a congested cough. That I also think was not indicated, and I'll discuss that tomorrow.

I looked up at the monitor and saw that the SAT was picking up just fine. I looked at it, turned around, and the doctor was gone but the nurse was standing right there.

"What'ja get," she said cheerfully.

"I get 94%. He should be good to go."

"He already bought himself a ticket upstairs."

"What!"

She looked at me with a look of surprise. "That's not a good enough SAT for him to go home with."

"94% is perfectly fine to go home with."

Her smile disappeared. "No it's not."

"Yes it is."

"Um, no it's not." She smiled to let me know no hard feelings.

I feigned a smile, but I was in rare form. "Yes he is."

"Not according to our pediatricians."

"The new thing is that a child can go home with any SAT over 91% if he's in no sign of distress, and this kid is fine."

The kid was fine. My daughter was 100 times worse than this kid, and we never even took her to the hospital.

"Well, our doctors, Dr. Hee and Dr. Haw, want a SAT to be 95% or better."

"Well, at a real hospital 94% is normal." Okay, so I didn't say that. I said, "At the big children's hospitals they have done research and determined that anything better than 91% is acceptable on a child this age." The kid was 2 months.

"Here it's 95%."

Tell me what the difference is between 94% and 95%. I didn't say it. I wanted to give her a smile as if to say no hard feelings, but I didn't. Instead stearnly turned around and exited the ER. I didnt' want to hurt her feelings, but I also wanted her to know I was serious. I was right.

One of the reasons I don't get vocal like this too often is that I have a conscience, and I don't want to hurt the other person's feelings. At the same time, I think it's high time our doctors and nurses read the latest research.

This is exactly the reason I keep up on my reasearch. Is it possible I know too much? Would it be better for me if I simply stopped learning? Is that what they want? Do they want me to stay stupid?

After all, a stupid RT asks no questions. A stupid RT cannot question a stupid doctor order or, in the case of this 95% SAT, stupid policies.

Stupid and outdated policies are really getting to me lately. And nurses and doctors who continue to live by and defend these old and outdated policies are likewise getting on my nerves.

I am very much aware that every doctor has his or her own opinion, and I know that each hospital has the right to have its own protocols. However, I think some good old fashioned common sense should be used in cases like this.

I could be wrong. What do you think?

Kid Albuterol season opens today

With the start of school comes the inevitable baby with cold, flu or Respiratory Syncytial Virus (RSV). And when doctors see these patients with their congested lungs and runny nose, a page to the respiratory therapist for a breathing treatment is eminent.

Amid my run of 10 p.m. breathing treatments tonight, I was called to the ER twice to give a treatment to 4-month-old babies with high respiratory rates, stuffy heads and snotty noses. I noticed no difference with either of the treatments.

"Oh, much better," the nurse said as I was finishing up the second treatment. "He should be able to go home now as soon as Rick does an RSV swab."

What evidence she used to come to that conclusion I had no idea.

Over thinking things as I usually do, I often wonder if breathing treatments even get down into a baby's little lungs. The particle size of medicines in the mist of a treatment is 5 microns, and that's the perfect size to fit into the bronchioles of an adult patient. But baby lungs are smaller than an adults, so how does the Ventolin fit in there.

I looked on the insert of a box of Albuterol, and it reads: " Albuterol... is indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm... The safety and effectiveness of Albuterol... in children below 2 years of age have not been established."

Obviously they were thinking the same thing. Regardless, Albuterol is the treatment of choice for stuffy and uncomfortable children under 2.

One study I read a few years back indicated that suctioning the airway was more effective than breathing treatments in treating patients with RSV. A breathing treatment may be attempted once, but if no improvement is observed, then no further treatments are indicated. In this case, I'd simply make this patient Q4 PRN.

Since these new studies and recommendations came out, not only do we give routine breathing treatments Q4, but we also use BBG nasal aspirators, otherwise known as booger be gones. That's progress I suppose.

Reasearch by American Family physician must have shown treatments do little for RSV patients, since their clinical practice guidelines state, "routine use of bronchodilators is not recommended.", and, "Studies also have not shown that bronchodilators have a long-term impact on the disease course."

The Cincinnati Children's Hospital Medical Center came to the same conclusion. Their guidelines also call for suctioning often.

Then again, everybody is subject to their own opinion. And, as has always been the case in the medical field, trying something as safe as a bronchodilator is better than doing nothing at all.

I know that there are certain qualifications that have to be met in order for insurance to pay, and breathing treatments for diagnosis of RSV is one of the qualifications. I personally think that's a puerile policy, but that's the way it is. Quite often, other than to make the family think we are doing something, this is the only reason I think we are doing most of these treatments. And this is unfortunate for me, because it burns me out, and for my asthma and COPD patients of whom are more deserving of my Albuterol Ampules.

Likewise, upon assessing hundreds of these children, I rarely notice a change in lung sounds, nor any improvement in retractions or nasal flaring if evident. There are obviously exceptions to the rule (baby's with real bronchospasms), but I find this to be true in most cases.

In all my research, I have never come across a study that conclusively confirms treatments do anything for these kids. I wonder if doctors are privy to esoteric knowledge, are grasping at old beliefs, or are simply ordering treatments because of the philosophy, "if it's pulmonary it should be treated as bronchospasm."

There is one other theory I have on the matter, and that is that the doctor orders Q4 ATC for no better reason than to make sure a respiratory therapist is checking on the patient. Some doctors, if this theory is accurate, feel more comfortable sleeping at home when they know their patients are in the high qualified and well respected care of the respiratory therapist.